Healthcare Fraud – the Nigeria Case by Livy-Elcon Emereonye

Science is the search for, and the practice of, truth. Its tools are rationality, objectivity, clarity, reproducibility, experimentation and the exchange of reliable information and services for the benefit of mankind. The process of science is governed by rationality, logic and truth; and the scientist through systematic activity objectively and critically observes, collect, classify and process information for a scientific result.

Health science, like every other science, is the search for truth – the truth for health promotion, disease prevention, management and treatment of ill-health. It is a noble pursuit that should be encouraged and appropriately utilized for the achievement of desired goal – good health.

Unfortunately, there are different types, and countless cases, of abuse and misuse in the health science and healthcare services than could be imagined that instead of getting good health, many people end up with ill health!

What is health?

According to World Health Organization, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It is “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.”

Physical health or physical wellbeing means a good body health, which is healthy because of regular physical activity (exercise), good nutrition, and adequate rest. It is something a person can achieve by developing all health-related components of his/her lifestyle. Other contributors to physical wellbeing may include bodyweight management, abstaining from drug abuse, avoiding alcohol abuse, responsible sexual behavior (sexual health), hygiene, and getting the right amount of sleep and rest.

Mental health refers to people’s cognitive and emotional well-being. A person who enjoys good mental health does not have a mental disorder. According to WHO, mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”. It includes the ability to enjoy life, the ability to bounce back from adversity, the ability to achieve balance (moderation), the ability to be flexible and adapt, the ability to feel safe and secure, and self-actualization.

Wellness, according to Mickinley Health Center, University of Illinois, “is a state of optimal well-being that is oriented toward maximizing an individual’s potential.” It is a life-long process of moving towards enhancing one’s physical, intellectual, emotional, social, spiritual, and environmental well-being. Wellness is the integration of mind, body and spirit that allows for achievement of goals with the ability to live life to the fullest and to maximize personal potential in a variety of ways.

From the above, health is holistic. And to be healthy, there should be a balance with the triad of health.

On the other hand, disease is a “state of a disordered or incorrectly functioning organ, part, structure, or system, resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors.” It can be synonymous with illness, sickness, or ailment. It mitigates productivity and longevity.

Anything short of good health is not desirable by every rational human being. Thus, the search for, and pursuit of, health through healthcare.

What is Healthcare?

Healthcare can be defined as “the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings.” It is delivered by practitioners in allied health, dentistry, midwifery (obstetrics), medicine, nursing, optometry, pharmacy, psychology and other health professions. Healthcare service refers to the work done in providing primary care, secondary care, and tertiary care, as well as in public health.

Healthcare extends beyond the delivery of services to patients, encompassing many related sectors, and set within a bigger picture of financing and governance structures. However, access to healthcare varies across countries, groups, and individuals, largely influenced by social and economic conditions as well as the health policies in place.

A health system, sometimes referred to as healthcare system, is the organization of people, institutions, and resources to deliver healthcare services to meet the health needs of target populations.

Healthcare contributes to a significant part of a country’s economy. For example, in 2011, the healthcare industry consumed an average of 9.3 percent of the GDP or US$ 3,322 (PPP-adjusted) per capita across the 34 members of OECD countries. The USA (17.7%, or US$ PPP 8,508), the Netherlands (11.9%, 5,099), France (11.6%, 4,118), Germany (11.3%, 4,495), Canada (11.2%, 5669), and Switzerland (11%, 5,634) were the top spenders, however life expectancy in total population at birth was highest in Switzerland (82.8 years), Japan and Italy (82.7), Spain and Iceland (82.4), France (82.2) and Australia (82.0), while OECD’s average exceeds 80 years for the first time ever in 2011: 80.1 years, a gain of 10 years since 1970. The USA (78.7 years) ranges only on place 26 among the 34 OECD member countries, but has the highest costs by far. All OECD countries have achieved universal (or almost universal) health coverage, except Mexico and the USA.”

Though there is no reliable data with Nigeria’s case, very huge amount of money has been involved and will continue to be involved.

And there is always a conspiracy where big money is involved, giving way in this case to healthcare fraud.

What is Healthcare Fraud?

Healthcare Fraud is the intentional deception or misrepresentation within the healthcare system by a healthcare provider with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It is a type of white-collar crime that involves the filing of dishonest healthcare claims in order to turn a profit. When a healthcare fraud is perpetrated, the healthcare provider passes the costs along to its customers. And it can involve physicians, pharmacists, beneficiaries, and even medical equipment companies.

Healthcare Fraud can take many forms, and includes health insurance fraud, drug fraud, and medical fraud. Health insurance fraud occurs when a company or an individual defrauds an insurer or government healthcare programme. Fraudulent healthcare schemes come in many forms. The manner in which this is done varies, and persons engaging in it are always seeking new ways to circumvent the law.

Aside healthcare professionals and allied workers, charlatans and quacks are involved in fraudulent healthcare practices in Nigeria. And some of them are stack illiterates yet they claim to cure all sicknesses and diseases, parading with the prefix, “Dr.”! Hardly can one move around major cities and streets without seeing these heartless tricksters perpetuating their nefarious trade. From displaying funny pictures and concoctions to playing loud irritating uninformed messages with speakers hung high on electric poles and dancing around with mascots and animals on chartered buses, they seek attention and indeed get it that ignorant masses, maybe under hypnotization, patronize them at exorbitant cost.

Types of Healthcare Fraud

Billing for services not rendered

Upcoding of services

Upcoding of items

Duplicate claims

Unbundling

Excessive services

Unnecessary services

Kickbacks

Medical identity theft

Rendering healthcare without a license

Billing for services not rendered: This is the act of billing for things that never happened. It can involve forging the signature of those enrolled in Healthcare, and the use of bribes or kickbacks to corrupt clinicians and Healthcare workers.

Upcoding of services: This a way of billing for services that are more costly than the actual procedure that was done.

Upcoding of items: This is similar to upcoding of services, but involves the use of medical equipment and medicines, for example billing for a power-assisted wheelchair when only a manual wheelchair was used or billing from an expensive branded product in place of a cheap generic.

Duplicate claims: Here a provider does not submit exactly the same bill, but changes some small portion like the date in order to charge twice for the same service rendered. Rather than a single claim being filed twice, the same service is billed two times in an attempt to be paid twice.

Unbundling: in this case, bills for a particular service are submitted in piecemeal, that appear to be staggered out over time. These services would normally cost less when bundled together, but by manipulating the claim, a higher charge is billed resulting in a higher pay out to the fraudster.

Excessive services: This is the act of billing for something greater than what the level of actual care or service requires.

Unnecessary services: This is the act of billing for care or service that in no way applied to the condition of a patient.

Kickbacks: They are rewards such as cash, jewelry, free vacations, corporate sponsored retreats, or other lavish gifts used to entice and induce clinicians or healthcare workers into using a particular product or specific medical services at expense of other available and equivalent ones.

Medical identity theft: This is the appropriation or misuse of a patient’s or provider’s unique medical identifying information to obtain or bill public or private payers for fraudulent medical goods or services. For example stolen physician identifiers can be used to fill fraudulent prescriptions, refer patients for unnecessary additional services or supplies, or bill for services that were never provided.

Rendering healthcare without a license: This applies to quacks and criminals that heartlessly defraud people in the name of healthcare. It also includes the use of unqualified or unlicensed staff.

Effect of Healthcare Fraud

Healthcare Fraud affects everyone. Healthcare Fraud costs tens of billions of dollars a year as the fraudsters steal billions of dollars each year through fraudulent or abusive practices. For instance, in 2010, the FBI estimated that Healthcare Fraud cost American tax payers $80 billion. It is such a wasteful, rising threat; and with national healthcare expenditures estimated to increase to trillions of dollars and spending continuing to outpace inflation, more fraud would be carried out yearly that health professionals might be more willing, to risk patient harm in furtherance of their schemes.

Apart from loss of revenue, the pervasiveness of healthcare fraud can lead to a decreased confidence in the healthcare system with resultant therapeutic failure, complications and premature death.

Call for action

Rooting out healthcare fraud is central to the well-being of both our citizens and the overall economy so if you suspect that healthcare bills are being paid improperly or as a result of false or misleading information, report to the appropriate authority. Take a step to protect yourself. Know your rights. Ask questions. Seek clarifications.

There are many ways to report cases of fraud. If a patient or health care provider believes they have witnessed Healthcare Fraud, they are encouraged to contact the appropriate authority through telephone, or mail.

The following guidelines can be used to safeguard one from preventable healthcare fraud and improve the quality of care received:

After care, review your statement to verify accuracy. Learn how to read your Explanation of Benefits

Ask your clinician to explain the reason for services

Report any discrepancies to appropriate authority

Beware of “free” medical services, as illicit entities use this lure to obtain information

Safeguard your insurance card the same as you would your credit card

Report instances where co-payments or deductibles are waived

Don’t give your insurance number to marketers or solicitors

Never sign a blank insurance form

Demand receipt for your transactions.

It is pertinent to note that healthcare providers who engage in fraud and abuse are subject to sanctions under a number of laws. Such sanctions can take the form of administrative, civil, and criminal penalties. The penalties can range from monetary fines and damages to prison time and exclusion from healthcare programmes, and possibly losing the right to practice in the healthcare industry.

And a successful prosecution of a healthcare provider that ends in a conviction can have serious consequence that would serve as a deterrent for others.

So by becoming familiar with common types of fraud and abuse, providers will be in a better position to ensure they are not involved in such conduct. They will also be better equipped to identify and report others who may be engaged in fraud and abuse.

In conclusion Healthcare Fraud is a crime against humanity. Apart from causing more health problems, it has condemned so many people to premature death. Thus, it must be checkmated, curtailed and prevented. And to do this, all hands must be on the deck.